Analysis Fatigue During the voyage downriver, the pilot was alternately sitting, standing, and walking to consult the radar and use the very high frequency (VHF) radiotelephone. Nothing in his actions before the grounding indicated less-than-adequate ability to perform. Although the pilot was experienced, the vessel was allowed to continue past the customary course alteration point by approximately three cables or, alternately, by 50seconds at a speed of 15knots. While the pilot had more than 24hours off between his previous assignment and the assignment on the Horizon, both assignments included working at irregular hours during the early morning. Consequently, these assignments would have had an effect on his sleep-wake pattern - the biological clock that regulates many of the body's daily functions. Reportedly, the pilot napped for a few hours in the early evening before his assignment. This may not have been restorative, as it occurred when his biological clock would have indicated wakefulness. Such conditions are conducive to fatigue. Although pilots have received fatigue awareness training and the contractual arrangements set out adequate rest for pilots, fatigue continues to be a factor in occurrences. Bridge Resource Management Just before the grounding, the Horizon was proceeding at about 15 knots. In restricted waters, it is imperative that orders for a course alteration and its execution are promptly carried out. The pilot, seated to port, was essentially the only person on the bridge who knew where the vessel was at any given time, due to his extensive local knowledge, training, and experience with this particular run of the river. Although the OOWput the vessel's position on the chart from time to time, he was, for the most part, standing near the engine room telegraph in case engine orders were needed. On the Horizon's bridge at night with the bridge team spread out, communication among members was minimal in the minutes leading up to the grounding. In order to be an effective bridge team member, the OOW must at all times possess a mental model similar to that of the pilot. Because of the extent of the restricted waterway (Montral to Trois-Rivires and beyond) it is unrealistic to think the OOW can navigate in real-time using radar parallel index techniques. However, continuous monitoring of the vessel's position in relation to the intended track by the OOW is necessary. One instrument with the potential to further safety of navigation in pilotage waters is the electronic chart system (ECS) or Electronic Chart Display and Information System (ECDIS). It allows complete, dock-to-dock routes to be stored in a computer memory. Continuous, real-time positioning is accurate, and the navigator can see the vessel to scale on the (chart) screen. Additionally, it permits auto-diagnostic alarms to be set to warn the bridge team when the ECDIS position information is unreliable. Properly used, an ECDIS complements existing instruments, especially in pilotage waters, and helps enhance BRM effectiveness. Although the Horizon is not equipped with an ECS/ECDIS, nor was it required to be, this equipment would have provided the OOW with cues and appropriate information at an early stage for decision making and action, and to effectively participate as a bridge team member.9 In this occurrence, without the benefit of local knowledge or other means to continually compare real-time vessel position with the intended track, such as ECS/ECDIS, the OOW did not intervene or otherwise challenge the pilot. BRM,10 originally born out of the airline industry as a product of the cockpit environment,11 has been widely accepted as a means to further navigation safety. Modern BRM theory and practice relies intimately on operation, which in turn is influenced by design. Successful application of BRM methodology, however, has been hampered by bridge layout and ergonomics. Bridge Ergonomics During the night-time trip downriver, the bridge team was spread throughout the darkened wheelhouse, with the various members attending to their respective duties. Communication among team members was limited. The pilot voiced headings to steer, and the helmsman repeated these headings as each manoeuvre was executed. Just before the grounding, the pilot, who was seated to port, was 3.3m from the helmsman at the steering stand and approximately 6.7m from the OOW, who was standing near the engine room telegraph. The bridge of the Horizon, for example, as well as many other vessels of even more recent construction, is essentially the same as those constructed in the 1950sor even earlier-only with more buttons, controls, and alarms to consider. Such a layout, which has not kept pace with advances in ergonomics and technology, is not conducive to BRM techniques and precise vessel control. Regulation 15 of ChapterV of the International Convention for the Safety of Life at Sea (SOLAS), as amended in2002, can be seen as innovative, with its premise that ship control is a socio-technical system.12 However, the classification societies under the umbrella of the International Association of Classification Societies have not yet formally adopted an accepted unified interpretation (UI) for the application of Regulation15.13 Without a UIor other agreed-upon method to demonstrate conformity among Class and/or flag states, Regulation15's intent and purpose may remain unfulfilled. Bridge layouts will continue to be a reflection of a bygone era, and thus conducive to single-point failure. Emergency Response The Horizon grounded in the ecologically sensitive area of the Sorel Archipelago. Although tides are not present, water levels can vary as much as 50cm within a few days, depending on rainfall and runoff from the Great Lakes. The channel bottom, composed primarily of sand and mud, presents no great dangers, and currents are light. Sea swell is not present, and the proximity of land in all directions means that wave action is reduced even in high winds. A salvage operation, however, can still prove challenging and time consuming, as this occurrence demonstrated. Previously, incomplete or improper assessment of all the variables, as well as inadequate emergency response, has caused incidents to escalate.14 Subsequent to the 1999Alcor grounding, the TSB recommended that contingency plans be developed, implemented, and exercised to ensure that risks associated with navigation-related emergencies are adequately addressed.15 It is the position of both TCand DFOthat it is the ship's responsibility to respond to an emergency such as grounding or an oil spill; federal agencies step in only when the safety of life or the environment is being threatened through inadequate response. Consequently, the two agencies' initial role is to monitor the accident. In the event that they do have to take direct action, it is necessary for this action to be firmly based on well-documented contingency plans that have been appropriately tested. Since the master does not usually possess in-depth knowledge of the grounding area or the resources that are available, the bridge team must rely on local experts for guidance. The initial attempts to free the vessel involved one tug, then two, three, and finally four. Attempting to refloat with the tools immediately at hand - de-ballasting and tugs-is understandable. However, in view of the extent of the lost buoyancy, it should have been apparent that lightering would have to be an essential component of any salvage attempt. Powerful tugs pulling at full capacity on an immovable vessel risk the dangerous failure of mooring equipment and tow lines, placing personnel at risk. The failure of such equipment when under load has been previously documented and is a concern atIMO.16 Notwithstanding the previous TSB recommendation and many examples worldwide of salvage attempts gone wrong,17 TCand DFOcontinue to address navigation-related emergencies such as groundings without the benefit of contingency plans and area-specific risk assessments. A United States Coast Guard paper on marine salvage succinctly states the issue: Salvage operations must be conducted with the utmost concern for safety of personnel, as well as protection of the marine environment and property. Due to the highly dynamic circumstances involved... there is no standard or foolproof method for responding.... Therefore, contingency planning and pre-established relationships with industry become indispensable to ensure informed decision making, maximum responder cooperation, and optimum asset coordination.18 Without proper preparation, government officials risk being unable to give timely and beneficial guidance to crews of vessels in difficulty - when time is of the essence - nor can they themselves take necessary measures if crews do not perform appropriately. Pilot Relief A refloating attempt is an extremely demanding undertaking. One of the elements necessary for a successful mission is the pilot's performance and his/her ability to retain full concentration. However, the need to quickly relieve a pilot involved in an occurrence has been recognized by the Great Lakes Pilotage Authority.19 Although the LPA recognizes the benefit of pilot relief subsequent to a marine emergency, there are no specific measures in place to promptly provide pilot relief. This means that relief can take up to 12hours because of the routine notice required. In this occurrence, the pilot on the Horizon, on his own initiative, requested relief soon after the grounding; however, he remained on board during the morning and afternoon of 24July2004 until relieved at1510. Degradation in pilot performance due to remaining on board has been identified as a factor in previous occurrences.20 In a safety communication addressed to the LPAin2001, the TSBemphasized that the lack of a formal post-accident pilot relief policy increases risks. The pilot, seated on the port side of the wheelhouse and having the conduct of the vessel, did not order a timely course alteration. Fatigue may have been a factor in the pilot's decreased vigilance at a critical time. The vessel's progress was not effectively monitored by the officer of the watch. In the minutes leading up to the grounding effective Bridge Resource Management techniques were not used and the communication between team members was minimal.Findings as to Causes and Contributing Factors The pilot, seated on the port side of the wheelhouse and having the conduct of the vessel, did not order a timely course alteration. Fatigue may have been a factor in the pilot's decreased vigilance at a critical time. The vessel's progress was not effectively monitored by the officer of the watch. In the minutes leading up to the grounding effective Bridge Resource Management techniques were not used and the communication between team members was minimal. In the event of a navigation emergency, Transport Canada and the Department of Fisheries and Oceans continue to operate without the benefit of detailed contingency plans and area-specific risk assessments. Initial refloating attempts were not based on sound salvage practices. Using powerful tugs under such circumstances that is pulling at full capacity on an immovable vessel - increased chances of failure of the mooring equipment or lines, placing personnel at risk. While the Laurentian Pilotage Authority recognizes the benefit of pilot relief subsequent to a marine emergency, there is no measure in place to promptly provide pilot relief. Despite fatigue awareness training and contractual arrangements that set out adequate rest for pilots, fatigue continues to be a factor in occurrences. Without the benefit of local knowledge or the availability of an electronic chart system (ECS) or Electronic Chart Display and Information System (ECDIS), an officer of the watch is largely reliant on visual means to monitor the vessel's track, which limits his or her ability to intervene effectively in complex pilotage waters.Findings as to Risk In the event of a navigation emergency, Transport Canada and the Department of Fisheries and Oceans continue to operate without the benefit of detailed contingency plans and area-specific risk assessments. Initial refloating attempts were not based on sound salvage practices. Using powerful tugs under such circumstances that is pulling at full capacity on an immovable vessel - increased chances of failure of the mooring equipment or lines, placing personnel at risk. While the Laurentian Pilotage Authority recognizes the benefit of pilot relief subsequent to a marine emergency, there is no measure in place to promptly provide pilot relief. Despite fatigue awareness training and contractual arrangements that set out adequate rest for pilots, fatigue continues to be a factor in occurrences. Without the benefit of local knowledge or the availability of an electronic chart system (ECS) or Electronic Chart Display and Information System (ECDIS), an officer of the watch is largely reliant on visual means to monitor the vessel's track, which limits his or her ability to intervene effectively in complex pilotage waters. Bridge ergonomics and layout on many vessels are not conducive to seamless Bridge Resource Management techniques and precise vessel control by a team.Other Finding Bridge ergonomics and layout on many vessels are not conducive to seamless Bridge Resource Management techniques and precise vessel control by a team. Safety Action Action Taken Since this occurrence and in response to an earlier recommendation subsequent to the grounding of the vessel Alcor in 1999 (recommendation M03-03), Transport Canada Marine Safety - Quebec Region (TC) and the Canadian Coast Guard (CCG) - Quebec Region (Department of Fisheries and Oceans [DFO]) have developed a guide that is used in assessing marine emergencies such as groundings. The DFO has indicated that it is currently concentrating on measures such as increasing the efficiency of information exchange and setting up an expert committee subsequent to a marine emergency. For the time being, area specific risk assessments and contingency plans cannot be undertaken due to lack of human and financial resources. From 31 October to 02 November 2006, the DFOand TCundertook a major simulation exercise to help prepare stakeholders at the various levels of government to deal with marine emergencies. Safety Concerns Both pilot fatigue and pilot relief have been issues raised in past Board reports and have been the subject of recommendations or safety concerns. Pilot Fatigue Pilot fatigue was the subject of Board recommendation M99-04. Canadian Pilotage authorities responded positively to this recommendation and fatigue awareness programs were initiated. Other fatigue mitigation measures in the Laurentian Pilotage Authority's jurisdiction, such as pilot service contracts that impose two pilots if the assignment is to take longer than 11consecutive hours, are in effect as well. However, as this occurrence has demonstrated, fatigue continues to be a factor. The Board is concerned that despite fatigue awareness training and contractual arrangements that set out adequate rest for pilots, fatigue continues to be a factor in occurrences. Pilot Relief Pilot relief subsequent to an occurrence has been the subject of past Findings,21 a Marine Safety Information Letter addressed to the Laurentian Pilotage Authority,22 as well as a factor mentioned in a Board safety concern relating to pilot performance.23 Although the Laurentian Pilotage Authority has expressed agreement, in principal, with the issue of relieving a pilot as soon as is practicable after an occurrence, the authority still does not have written procedures or policies that embed these measures into its operations. Other pilotage authorities, such as the Great Lakes Pilotage Authority, have had such procedures for quite some time. Even though the vessel was easily accessible from the port of Sorel, Quebec, and the occurrence pilot requested relief soon after the grounding, he remained on board to the full extent of the allowable time as specified in the service contract before being relieved. During this time the pilot was helping the master carry out tug work for the initial refloating attempts and making other safety critical decisions. The Board is concerned that, despite an agreement in principal by the Laurentian Pilotage Authority, risks are still greater than they could be in this jurisdiction due to pilots not being relieved as soon as is practicable after a serious occurrence. Emergency Response Timely and effective emergency response to navigation-related occurrences such as groundings is paramount in reducing risks to the environment and the transportation system. In most cases, the response will be adequately handled by the vessel owners and a contracted salvage company. Only in the case when the owner's response is not adequate or timely will government agencies take action themselves as opposed to monitoring the action of others. In the present case, the risks presented to the environment and navigable channel were low - and the vessel's owner took the required action in a timely manner. Both TC and the DFO are particularly well attuned to responding, in a coordinated fashion, to pollution incidents and life threatening incidents or accidents by way of the national search and rescue scheme that includes rescue co-ordination centers, equipment and personnel. However, as documented in past reports such as the Alcor (M99L0126), these agencies are not well prepared to quickly and effectively deal with salvage issues. Since this occurrence, TC Marine Safety Quebec Region and the DFO (CCG - Quebec Region) have cooperated in developing a guide that will be used to assist decision making when assessing marine emergencies such as groundings. Although it is currently relevant only to the Quebec region, the Board is encouraged by progress being made. The DFO (CCG - Quebec Region) is also concentrating on increasing the efficiency of information exchange and setting up an expert committee subsequent to a marine emergency. However, the Department of Fisheries and Oceans has informed the Board that, for the time being, area-specific risk assessments and contingency plans cannot be undertaken due to lack of human and financial resources - even though this work is fundamental to laying the foundations for effective and timely risk-based decision making in the event of an occurrence such as grounding. The Board believes that a planned and coordinated approach is necessary to deal with navigation-related emergencies in Canadian waters while supporting the vessel owners' efforts to deal with an occurrence. The Board is therefore concerned that the continuing lack of comprehensive contingency planning for navigation related emergencies will continue to place vessels, crew, and the environment at risk. The Board will continue to monitor these safety issues.